Disease Consequences of Bidi Smoking | Lung Disease -Jindal Chest Clinic

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Disease Consequences of Bidi SmokingLung Disease

• S. K. Jindal
• Professor and Head
• Department of Pulmonary Medicine
• Postgraduate Institute of Medical Education
  Research
• Chandigarh, India

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Global Burden of Disease Study (1997)

• Specific causes of disability (DALY)
• LRTI 1st
• COPD 12th
• Asthma 30th
• Causes of death LRTI, COPD
• TB and Lung Cancer 9.4 million death
• (Top ten leading causes)

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Tobacco Smoking and Lung Diseases

• Established relationships since 1960s
• COPD (Chr. Obstructive Pulm. Disease)
• Respiratory infections
• Asthma and Bronchial hyper-responsiveness
• Impaired lung function
• Lung Cancer
• Others TB, ILDs, Pneumonias

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Smoking habits in rural areas
No. of Proportion Smoking product Smoking product Smoking product
subjects of smokers Cigarette Bidi Hookah
Men
Chandigarh 5333 40.48 13.34 81.47 5.19
Delhi 3933 41.42 12.65 78.21 9.09
Kanpur 3921 26.32 6.30 92.54 0.78
Bangalore 4111 34.71 18.57 81.43 0.00
Total 17298 36.11 13.19 82.44 4.29
Women
Chandigarh 4976 5.53 8.00 76.00 16.00
Delhi 3749 7.47 3.21 56.79 40.00
Kanpur 3278 1.59 3.85 96.15 0.00
Bangalore 4003 0.00 - - -
Total 16006 3.79 5.44 68.86 25.70
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Smoking habits in urban areas
No. of Proportion Smoking product Smoking product Smoking product
subjects of smokers Cigarette Bidi Hookah
Men
Chandigarh 5717 20.01 53.41 45.45 1.05
Delhi 4033 17.85 37.92 60.97 0.97
Kanpur 6107 19.16 40.17 59.74 0.09
Bangalore 4527 32.58 56.07 43.93 0.00
Total 20384 22.12 48.37 51.14 0.44
Women
Chandigarh 5638 0.96 20.37 68.52 11.11
Delhi 3927 1.07 11.90 71.43 16.67
Kanpur 5552 0.65 16.67 80.56 2.78
Bangalore 4800 0.02 100.00 0.00 0.00
Total 19917 0.67 17.29 72.18 10.53
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COPD (vs. Asthma)

• Chronic, progressive, irreversible narrowing of
  airways ? Chronic respiratory failure
• Includes Chronic bronchitis and Emphysema
• Chronic cough, expectoration, breathlessness
• Chronic respiratory disability and early death
• Prevalence (Population gt 30 yrs age)
• M 5 F 2.7
• Major cause of global disease and economic burden

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Airway lumen
Airway wall
Smooth muscle
Mucus glands
Smooth muscle hypertrophy
Inflammation and edema
Airway narrowing
Mucus plugging
Mucus gland hypertrophy and hyperplasia
Normal airway
Airway of a smoker
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COPD and Smoking

• Recognized since 1950s
• Epidemiological, clinical and exptl. data
• Royal College of Physicians, London 1962
• US Surg Gen reports 1964 1984
• GOLD 2001

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A summary of studies from India and Nepal on
prevalence of COPD (Chronic Bronchitis and/or
Emphysema) in male subjects and its smoking
associations
Authors Population No. of subjects No. of subjects COPD () COPD ()
Smoker Non smoker Smoker Non smoker
Wig et al9 Delhi Urban 302 276 0.7 5.8
Rural 115 181 2.6 12.1
Viswanathan30 Delhi- i. Textile mills 807 185 3.0 19.5
ii. Patients' attendants 174 43 3.5 13.3
iii. University staff 563 93 4.6 15.1
Viswanathan et al10 Patna area 14119 1686 1.1 7.3
Sikand et al6 Delhi 1052 449 2.8 16.9
Joshi et al5 Ludhiana (N.India) industrial workers 229 244 3.9 20.5
Bhattacharya et al13 Lucknow- rural 544 596 4.2 7.0
Thiruvengadam et al23 Madras 762 55 1.2 7.4
Viswanathan Singh7 Delhi Urban 788 205 3.9 15.6
Rural 770 231 1.4 13.4
Radha et al14 Delhi- Urban 436 338 4.3 8
Charan12 Punjab- rural 7132 7132 0.7 0.7
Including ex-smokers
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A summary of studies from India and Nepal on
prevalence of COPD (Chronic Bronchitis and/or
Emphysema) in male subjects and its smoking
associations
Authors Population No. of subjects No. of subjects COPD () COPD ()
Smoker Non smoker Smoker Non smoker
Malik Singh31 Haryana- rural 81 197 0 21.6
Malik et al8 North India 810 334 4.0 19.0
Malik Wahi32 North India, both urban and rural 1580 780 5.2 20.0
Shrestha Pandey11 Kathmandu, Nepal-rural 1427 1427 4.3 13.5
Malik et al33 Chandigarh city ,N.India 10061 444 1.0 9.9
Nigam et al34 Jhansi N. India-rural 115 660 6.1 8.5
Pande et al27 Nepal, hills 2826 449 18.3 16.9
Malik et al35 Himachal rural hills 120 184 5.8 32
Behera et al36 Chandigarh-Teachers 270 63 3 4.8
Jindal (follow up) 37 N. India Urban 296 60 0.3 21.7
Rural 139 84 2.2 13.1
Ray et al38 Tamil Nadu South India 9946 9946 3.3 3.3
(incl. Ex-smokers Numbers restudied
after 10 years of the original 1450 urban and 671
rural subjects studied in 1980 Of 198 male
COPD subjects, 62 were smokers of whom 87
smoked bidis.
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Summary of studies on COPD Prevalence in Bidi
smokers
Total COPD Prevalence () COPD Prevalence () COPD Prevalence () COPD Prevalence ()
number Non smoker Cig. smoker Bidi smoker Mixed smoker

Bhattacharya et al 1140 4.2 - 3.1 -
Radha et al 774 4.35 6.02 8.33 15.7
Malik Wahi 2360 5.2 13.3 17.2 19.6
Malik et al 2816 1.0 8.8 9.0 8.5
Nigam et al 775 6.1 4.3 4.6 -
Jindal et al 1473 2.2 21.7 13.1 -
Excludes the high prevalence of 25 seen in
ex-smokers (mostly bidis)
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COPD and Bidi Smoking (Males)
Initial Study (1977-1980) Follow up Study (1990)
No. of subjects 4372 1475 (33.7)
Smokers Cigarettes (U) Bidis (R ) 444 286 60 (13.5) 84 (29.4)
COPD Prevalence Nonsmokers Smokers Cigarettes (U) Bidis (R ) 25 (1.8) 44 (0.9) 47 (16.4) 4 (0.9) 14 (21.7) 11 (13.1)
Total 91 (12.5) 25 (15.2)
(Malik 1986 Jindal SK 1993) (Malik 1986 Jindal SK 1993) (Malik 1986 Jindal SK 1993)
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Odds of having chronic bronchitis for different
smoking products
Chandigarh Delhi Kanpur Bangalore

Cigarette 2.446 (1.602-3.734) 3.517 (2.293-5.395) 1.072 (0.619-1.856) 1.781 (1.330-2.385)

Bidi 3.003 (2.262-3.987) 3.853 (2.988-4.970) 2.425 (1.906-3.084) 2.793 (2.306-3.381)

Hookah 9.472 (5.902-15.20) 3.167 (1.881-5.333) 9.619 (1.931-47.91) -
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Bidi Smoking and Asthma

• Triggering of asthma (Cig vs. bidi ?)
• Symptomatic prevalence of asthma in smokers (vs
  nonsmokers)
• Total No. 73605 O.R. 95 CI
• Cig. smoking 2.12 1.76-2.55
• Bidi smoking 1.97 1.73-2.23

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Odds of having bronchial asthma for different
smoking products
Chandigarh Delhi Kanpur Bangalore

Cigarette 2.540 (1.843-3.501) 2.988 (1.866-4.785) 1.641 (0.985-2.733) 1.515 (1.123-2.042)

Bidi 1.742 (1.366-2.223) 2.104 (1.550-2.857) 2.207 (1.688-2.885) 2.025 (1.632-2.511)

Hookah 7.809 (4.972-12.26) 2.125 (1.036-4.359) 6.005 (0.758-47.54) -
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Bidi Smoking BHR

• BHR increased in bidi smokers
• Asymptomatic 54.5
• Symptomatic 83.3
• Greater the Smoking Index, lower the
• baseline FEV1 PD20 i.e. greater the BHR.
• Jindal et al 1985, 1987

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Bidi Smoking and Lung Function

• Evidence of airflow obstruction
• Malik and Wahi, 1978
• Swaroop Agnihotri, 1998
• Khan et al, 2002
• Chhabra et al, 2001
• Dhand et al, 1985

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A summary of reports from India on tobacco
association of Lung cancer
Smoking association Smoking association
Total no. NS ratio
Viswanathan et al, 196256 95 2.1
Shankar et al, 196757 20 5.7
Nagrath et al, 197058 35 1.9
Guleria et al, 197159 120 2.0
Basu et al, 197160 24 5.0
Jha et al, 197261 25 5.3
Nafae et al, 197362 25 7.3
Malik et al, 197663 136 3.5
Narang et al, 197764 58 4.8
Jindal et al, 197965 150 2.4
Notani et al, 197466 520 3.9
Malhotra 198667 70 4.8
Jindal et al, 198768 480 3.0
Jindal et al, 199069 1009 2.7
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Lung Ca and Bidi Smoking

• Mumbai RR (Bidis) 3.38
• (Notani et al 1977)
• Chandigarh O.R. 95 CI
• (Gupta et al 2001) Bidi 5.76 3.42-9.7
• Cig. 5.64 3.15-10.1
• Total No. Lung Ca 265
• Controls 525

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SUMMARY

• Bidi smoking is causally associated with
• Increased incidence of COPD
• Impaired lung function tests
• Increased BHR
• Increased ORs for asthma
• Higher incidence of lung cancer
• The risks for smoking of bidis are at least
  similar to those of cigarettes